the Naptown Medic: Violence against EMS

Safety Sunday, Volume 1. Issue 3 (3/24/13)

Violence against EMS: A freighting trend

I was going to address this very important and very complicated topic at some time, though some recent events have made me interested in addressing this topic sooner. Early last Thursday, during the last few hours of my last shift on my truck (before I moved to a truck closer to home) my partner and I responded on the old standby “sick person.” What started as a seemingly unresponsive 25 year old laying in his own vomit ended as an all-out throw down with 5 people holding him down and us calling for police. Though nobody was struck, the attempted restraining of a limb led my partner to strain his shoulder, thus ending our last shift together 4 hours early. The shift before my partner and me were struck by feet and hands and advised to “die” by our confused diabetic patient.

Months earlier a news story was done about an elderly woman who struck a coworker of mine with her cane. Just an hour ago I heard that one of new partners had a 14” dagger pulled out of cane on him. The patient had reportedly been in a secured psychiatric facility with the cane multiple times. About 14 years ago at my service a paramedic was shot in the abdomen in the emergency department. These few examples are just examples from one service, and just the ones I can think of or have heard of.

Nationally the risk of non-fatal assaults leading to lost work time is 60 per 10,000 workers. This compares to the national average of just 1.8. We are more than 30 times the national average to have these non-fatal assaults. In a 5 year look at statistics it was found that there were 10 violence related fatalities, about 3 times higher than the average worker. In an NAEMT survey they found that 52% of respondents had been victims of assaults. (most items are from Skip Kirkwood’s August 2012 EMS World article Violence against EMS Providers)

So, we have established that you are more likely than not to be assaulted in this career. Next we have to decide what to do about it. Some have advocated for use of firearms. I think there are plenty of other things to do than add guns to the situation. Guns may help in certain situations, but most likely the employer is missing an opportunity to have more “bang for their buck” somewhere else. In another study it was found that 54% of providers did not provide any training on how to deal with violent patients.

There have been some good resources released in writing about the assessment of body language in determining if a threat may be imminent. Some highlights of those include (from DT4EMS instructor Jerry MacCauley): Other DT4EMS videos, very good and free, can be found here.

Eyes

Pupils dilate and contract depending on the emotional state of the person. True, there are physiological reasons also, such as drugs/alcohol, bright lights, etc., but they are often a good indicator. The pupils can grow up to 4 times their normal size when a person is excited. They tend to constrict when someone is angry. More often than not, we use our eyes to gather information. People will look at a target before attacking it, just as we look at an object before picking it up. The advantage to us, if we catch it in time, is the time delay between the look and the movement. Any warning we get helps! Occasionally, a person will use eye contact as a way to establish dominance or intimidate others. There will be a break in eye contact just before the aggression is unleashed.

Head

When you look at a persons head, pay attention to the position it is held in. Is it back? This is usually a sign of aggression, such as winding up to thrust it forward. If it is straight, that could indicate assertiveness and forward may be a sign of submission or indecision.

Face

Muscles in the face can indicate tension. Clenched teeth, narrowing of the eyes and ears back can all indicate anxiety or aggression. Check for changes in skin color because this can tip you off to anger, fear or rage. Skin generally appears pale with rage or fear and reddens with anger. Also, aggressors tend to distort their faces slightly on the left side near the mouth. Check for tight or tense lips as an aggression clue.

Arms

Arms that are crossed high on the chest, sometimes with closed fists. Can indicate aggression, while arms that are held lower in front of the body is usually a non aggressive stance.

Hands

Opening and closing of the hands is an indication of anxiety. Ask yourself why he might be nervous. Perhaps one hand open and one hand closed could indicate a hidden weapon. Hands held close to the body may be hiding the telltale print of a concealed firearm or just a form of defensiveness. Watch how a police officer stands when he is in a crowd.

Legs and Stance

Rocking from toes to heels could be seen as aggressive, as in bobbing up and down on the balls of the feet. A martial arts or a boxer’s stance is also an obvious indication of an aggressive individual. A trained fighter will shift 90% of their weight to the back leg prior to attacking.

This is an important factor in DT4EMS’s approach to mitigating violence on EMS workers. Here are all of their 6 steps. Linked below will be the whole article.

At the crux of the DT4EMS approach is a series of six steps:

1) Don't be on an unsafe scene--This is not always possible. Obviously, providers are often assaulted on scenes they thought were safe. But we should strive to stay away from areas known to be trouble-prone. This will be the subject of our next article, appearing in July.

2) Awareness--Providers must be aware of their surroundings to prevent assaults. Be mindful of who is around and pay attention to the little things: What is being said? What are people's moods? Where are the exits, should the scene become unsafe?

3) Maintain a safe distance--If a scene starts going south, a provider should keep his/her hands up and open (a posture of nonaggression) and back away to about 6--8 feet, if possible (see Figure 1). This body language makes it clear the provider is not the attacker and not looking for a fight. Verbal skills are important at this stage, when words can still defuse a potentially violent situation.

4) Double tap parry--The DTP is the primary physical skill taught to defend against the majority of frontal attacks. It has three overlapping parts: the parry, momentary elbow control, and distraction. The DTP can be used in a variety of situations toward the ultimate end of escape.

5) Basic ground defense--If the DTP failed, contact (punch, grab, push, etc.) was made and the provider was knocked to the ground, the provider would tuck their chin, bring their knees up and yell on their way down. BGD tactics can keep an attacker from mounting (straddling) the fallen provider.

6) Escape the mount--If a provider is knocked down and mounted by an attacker (Figure 4), this teaches them how to escape and use BGD to create space.

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Well I hope that helped, there is also a term that you may hear frequently when looking at some of these issues. Situational awareness is the philosophy of being aware of your environment to notice potential future problems and address them. A couple of years ago I went to a conference and heard Rich Gasaway, PhD talk about the issue in depth. I have since followed him on twitter and constantly utilize him as a resource. Here is his website, with upcoming trainings, books, and other tips and tricks. http://www.richgasaway.com/